RETRACTED.

BACKGROUND: Upon the addition of the numbers corresponding to various cancer anatomical locations in the report published by Statistics South Africa (StatsSA), the absolute number and proportion of deaths due to all cancers increased from 36 726 (8.0%) in 2013 to 40 460 (8.5%) in 2015. These high figures suggest that malignant neoplasms were in fact the second-most frequent cause of death in South Africa (SA) in 2013, and moved to the first rank in 2015. OBJECTIVES: To support the initiative aimed at reducing cancer mortality in SA. To this purpose, we assessed trends in cancer mortality rates among males and females in SA from 1997 to 2016 to better understand the increasing threat of cancer mortality in SA. METHODS: The general mortality data for the period 1997 - 2016, as captured from death certificates in SA, was retrieved from StatsSA. Agestandardised mortality rates (ASMR) for each year were computed using the world standard population structure proposed by Segi as the reference population. The adjusted rates were reported per 100 000 population per year. The years of potential productive life lost (YPPLL) due to cancer deaths were calculated for each age group and gender. RESULTS: There were 681  689 total cancer deaths from 1997 to 2016, with 51.1% males and 48.9% females. Males had higher mortality rates than females. The ASMR ranged from 105.0 to 129.2 and 67.9 to 88.3 per 100 000 population per year among males and females, respectively. In 2004, the cancer mortality rate increased significantly among males (129.2 per 100 000 population), which was 1.5 times higher than in females (88.3 per 100 000 population). Among males, cancer of the lung had the highest YPPLL (394 779.3), followed by oesophageal (253 989.4) and liver (207 911.0). The YPPLL for cancer of the cervix (647 855.5) ranked first, followed by breast (483 863.6) and lung (146 304.6) in females. CONCLUSION: Cancer mortality rates have increased since 1997, regardless of gender. Overall, there was a decline in YPPLL for cancer in the young population, while it increased in the adult population. A significant reduction in cancer deaths could be achieved by broadly applying effective interventions.

Pancreatic cancer mortality in South Africa: A case-control study.

BACKGROUND: There are variations in the numbers of pancreatic cancer deaths reported annually in South Africa (SA). Since pancreatic cancer deaths in SA from 1997 to 2016, the number of cases has hugely increased, and reached 23 581 in both sexes. Sex differences are likely to contribute to the variations in the strength of associations between the risk factors and pancreatic cancer mortality. OBJECTIVE: To identify factors associated with an increased risk of pancreatic cancer mortality in SA. METHODS: A matched case-control study with 1:1 matching was conducted using data collected by Statistics SA from 1997 to 2016. Controls were randomly selected to be as similar as possible to the cases, and matched by age, sex and year of death. Conditional logistic regression was used to identify factors associated with pancreatic cancer mortality. RESULTS: This case-control study comprised a final selection of 23 581 cases (12 171 males and 11 410 females) and 23 581 controls (12 171 males and 11 410 females). A significantly increased risk of pancreatic cancer mortality was observed among males who were managers (odds ratio (OR) 2.99; 95% confidence interval (CI) 1.36 - 6.60; p=0.006) and craft and related trade workers (OR 1.89; 95% CI 1.14 - 3.14; p=0.013). Elevated risks of pancreatic cancer mortality were also found among females who were managers (OR 6.13; 95% CI 1.32 - 28.52; p=0.021), professionals (OR 2.12; 95% CI 1.24 - 3.63; p=0.006), clerical support workers (OR 3.78; 95% CI 1.79 - 7.98; p=0.001) and elementary occupation workers (OR 1.41; 95% CI 0.99 - 2.00; p=0.059). Smoking was significantly associated with pancreatic cancer mortality in females (OR 1.36; 95% CI 1.02 - 1.82; p=0.039). Working in several occupations was associated with an increased risk of pancreatic cancer mortality in males (OR 1.31; 95% CI 1.01 - 1.71; p=0.045) and females (OR 1.66; 95% CI 1.30 - 2.12; p<0.001). CONCLUSION: Smoking and certain occupations increased the risk of pancreatic cancer mortality. Further research is needed to evaluate the associations between other extrinsic and intrinsic factors and pancreatic cancer mortality.

The reliability of the modified lower extremity functional scale among adults living with HIV on antiretroviral therapy, in Rwanda, Africa.

Peripheral neuropathy (PN) is common among people living with HIV (PLHIV) on antiretroviral therapy (ART), and affects their daily functional ability and quality of life. Lower extremity functional ability, which is most commonly compromised in patients with PN, has not been clearly evaluated in an African setting, with regard to functional limitations. The lower extremity functional scale (LEFS) was originally developed and validated among elderly people in the USA, where the environment and activities of daily life are very different from those in Rwanda. The purpose of this study was to adapt and establish the reliability of LEFS, among adults living with HIV on ART, in a Rwandan environment. The study translated LEFS from English to Kinyarwanda, the local language spoken in Rwanda, the LEFS was then modified accordingly, and tested for test-retest reliability among 50 adult PLHIV on ART. An average Spearman rank order correlation coefficient, ρ ≥ 0.7, was considered optimal for reliability. Prior to the modification of the LEFS and in the initial testing of the translated LEFS, none of the activities was strongly correlated (ρ ≥ 0.8); most of the activities (90%, 18/20) were moderately correlated (ρ ≥ 0.5) and 10% (2/20) were weakly correlated (ρ ≤ 0.5). The ρ of most of the functional activities improved after modification by an expert group to ρ ≥ 0.7, establishing reliability and validity of LEFS among PLHIV on ART with lower extremity functional limitations, in this environment. In conclusion, this study demonstrated the importance of modifying and establishing test - retest reliability of tools derived from developed world contexts to local conditions in developing countries, such as in Rwanda. The modified LEFS in this study can be used in Rwanda by clinicians, specifically at ART clinics to screen and identify people with functional limitations at an early stage of the limitations, for treatment, rehabilitation and/or referral to appropriate health care services.

Patterns and predictors of joint damage as assessed by the rheumatoid arthritis articular damage (RAAD) score in South Africans with established rheumatoid arthritis.

This study aimed to determine the pattern and predictors of joint damage measured by the rheumatoid arthritis articular damage (RAAD) score and to describe its relationship to functional disability in patients with established rheumatoid arthritis (RA). One hundred Black patients with RA of disease duration ≥5 years were studied cross-sectionally. Data collected included socio-demographics, disease duration, smoking, body mass index (BMI), extraarticular features, rheumatoid factor (RF), haemoglobin (Hb), disease activity (DAS28), delay in disease-modifying antirheumatic drug initiation (DMARD lag) and treatment history. As outcome measures, the RAAD score and modified Health Assessment Questionnaire (mHAQ-DI) were used to assess joint damage and disability, respectively. Data were analysed by univariate and multivariate analyses. The mean RAAD score was 28.2 ± 12.8 for a mean disease duration of 17.5 ± 8.5 years. The majority of patients still had active disease (mean DAS28 4.4) and severe disability (mean mHAQ-DI 1.9), reflected in part by a long mean DMARD lag (9 years). Wrist and ankle joints were commonly involved. Multivariate analysis revealed that longer disease duration, higher RF titres and lower BMI were significant independent predictors of a higher RAAD score. The mHAQ-DI was significantly associated with DAS28, RAAD, education and Hb. Our results provide support for aspects of validity of the RAAD score and for its use in under-resourced settings. Further longitudinal studies are needed to evaluate its sensitivity to change in monitoring joint damage. Patterns of joint involvement and the inverse relationship between BMI and joint damage also merit further investigation in Black RA patients.

The outcome of mental health care users admitted under Section 40 of the South African Mental Health Care Act (No 17 of 2002).

OBJECTIVE: To determine the outcomes of mental health care users (MHCU's) admitted in terms of Section 40 of the South African Mental Health Care Act (No 17 of 2002) (MHCA) and the factors, if any, that are associated with these outcomes. METHOD: The study was a retrospective record review of MHCU's, 18 years and older, referred by the South African Police Service (SAPS) to Chris Hani Baragwanath Hospital (CHBH). All mental health care users handed over to CHBH by SAPS with completed MHCA form 22's during the period July 2007 to December 2007 were included in the study. The outcomes, demographics and clinical characteristics of these referrals were obtained from hospital records. RESULTS: During the six-month study period, 718 MHCU's were referred by members of SAPS to the CHBH Emergency Department. Associations were found between discharged MHCU's and i) being male, ii) being less than 35 years of age, iii) being unemployed, iv) having a lower level of education, v) having a past history of substance abuse and/or vi) a past psychiatric illness. Females were twice as likely to be unemployed and admitted to hospital (either to a psychiatric or general medical ward). MHCU's diagnosed with delirium were more likely to be admitted into a medical ward as compared to a psychiatric ward. CONCLUSION: As has been the case in most countries where police services have been incorporated into mental health acts, South Africa's new Mental Health Care Act (No 17 of 2002) has resulted in a large number of referrals by the police to mental health services. However, many of these referrals may not be necessary as most MHCU's end up not being admitted. The characteristics of police referrals suggest that the receiving facility should have the capacity to identify factors that favour outpatient care (especially substance abuse problems) and divert MHCU's presenting with such factors to appropriate treatment facilities without admitting them to the hospital.

Case fatality of patients with stroke over a 12-month period post stroke.

INTRODUCTION: Stroke is among the top 4 causes of death in South Africa and the top 10 leading causes of disability worldwide. There is a dearth of literature on stroke incidence, prevalence and outcome in sub-Saharan Africa. We aimed to establish the case fatality of stroke patients over a 12-month period post discharge from hospital. METHODS: A total of 200 patients with first-time ischaemic stroke were recruited from Chris Hani Baragwanath Academic Hospital and followed up for 12 months. The Barthel Index (BI) and Rivermead Mobility Index (RMI) were used to establish patient functional ability and, by inference, stroke severity. Follow-up assessments were performed at 3, 6 and 12 months post discharge. Data analysis was largely descriptive in nature. RESULTS: Thirty-eight per cent of patients died within the 12 month follow-up period; 25.5% within 3 months of discharge. The average length of hospital stay was 6 days. Low BI scores at discharge were observed in the majority of patients who died. CONCLUSION: The 12-month cumulative mortality was high (highest at the 3-month follow-up). The short hospital stay and poor functional ability of the patients post stroke possibly left them vulnerable to bed-rest complications, such as chest infections and pressure sores.

Exaggerated circulating Th-1 cytokine response in early rheumatoid arthritis patients with nodules.

BACKGROUND: Immunohistochemical studies of the rheumatoid nodule (RN) suggest it is a Th1 granuloma, with focal vasculitis, yet the pathogenesis remains unclear and little is known about circulating cytokines in these patients. OBJECTIVE: We studied circulating cytokines in DMARD-naïve RA patients to investigate associations with subcutaneous RN. METHODS: 149 DMARD-naïve adults with early RA (symptom duration ≤ 2 years) were assessed using the Simplified Disease Activity Index (SDAI), and hand and feet radiographs were scored using the modified Larsen method. Circulating cytokines and growth factors representative of T-helper cell 1(Th1) and Th2 cell, macrophages, and fibroblasts were measured using the Bio-Plex® suspension array system. RESULTS: Of 149 patients, 34 (22.8%) had subcutaneous RN, and these patients had more severe disease with higher mean swollen joint counts (p=0.02), SDAI (p=0.04) and modified Larsen scores (p=0.004). There were no differences in Rheumatoid Factor or anti-cyclic citrullinated peptide antibody positivity between patients with RN and those without RN. Patients with RN showed significantly higher levels of circulating IL-12 (p=0.02), IL-2 (p=0.048), and VEGF (p=0.033) levels, with a trend towards higher levels of IL-7 (p=0.056), IFN-γ (p=0.059) and IL-8 (p=0.074) compared to those without RN. CONCLUSIONS: DMARD-naïve early RA patients with RN had more severe disease than those without RN, and showed an exaggerated circulating Th1 and macrophage cytokine profile.

Functional disability and health-related quality of life in South Africans with early rheumatoid arthritis.

BACKGROUND: The severity and predictors of functional disability and health-related quality of life (HRQoL) in a cohort of South Africans with early rheumatoid arthritis (RA) were investigated. METHODS: Changes in the Health Assessment Questionnaire Disability Index (HAQ) and the 36-Item Short Form Health Survey (SF-36) following 12 months of traditional disease-modifying anti-rheumatic drugs (DMARDs) were studied in previously DMARD-naïve adults with disease duration ≤ 2 years. RESULTS: The majority of the 171 patients were female (82%), Black Africans (89%) with a mean (SD) symptom duration of 11.6 (7.0) months. In the 134 patients seen at 12 months, there were significant improvements in the HAQ and all domains of the SF-36 but 92 (69%) still had substantial functional disability (HAQ > 0.5) and 89 (66%) had suboptimal mental health [SF-36 mental composite score (MCS) < 66.6]. Multivariate analysis showed that female sex (p = 0.05) and high baseline HAQ score (p < 0.01) predicted substantial functional disability at 12 months. Unemployment (p = 0.03), high baseline pain (p = 0.02), and HAQ score (p = 0.04) predicted suboptimal mental health, with a trend towards a low level of schooling being significant (p = 0.08). CONCLUSIONS: Early RA has a broad impact on HRQoL in indigent South Africans, with a large proportion of patients still showing substantial functional disability and suboptimal mental health despite 12 months of DMARD therapy. Further research is needed to establish the role of interventions including psychosocial support, rehabilitation programmes, and biological therapy to improve physical function and HRQoL in this population.

Response to traditional disease-modifying anti-rheumatic drugs in indigent South Africans with early rheumatoid arthritis.

The clinical response to traditional disease-modifying anti-rheumatic drugs (DMARDs) in indigent South Africans with early rheumatoid arthritis was investigated. A cohort of patients with early (≤2 years) RA who were DMARD-naïve at inception were prospectively assessed for response to DMARDs using the Simplified Disease Activity Index (SDAI) over a 12-month period. Patients with low disease activity (LDA) at 12 months were compared to those with moderate and high disease activity with respect to demographic, clinical, autoantibody and radiographic features. The 171 patients (140 females) had a mean (SD) age of 47.1 (12.4) years, symptom duration of 11.7 (7.1) months and baseline SDAI of 39.4 (16.2). There was a significant overall improvement in the SDAI and its components in the 134 (78.4%) patients who completed the 12 months visit, but only 28.4% of them achieved LDA. The majority of patients (91%) were treated with methotrexate as monotherapy or in combination with chloroquine and/or sulphasalazine. Baseline features that independently predicted a LDA state at 12 months were lower Health Assessment Questionnaire Disability Index (p = 0.023) and a higher haemoglobin level (p = 0.048). Receiver operating characteristic curve analysis showed that the 6-month SDAI was better than the baseline SDAI in predicting the 12-month SDAI (area under the curve of 0.69 vs. 0.52, respectively, p = 0.008). In conclusion, less than a third of the patients achieved a low disease activity at 12 months on traditional DMARDs. Patients who have an inadequate response to traditional DMARDs at 6 months are unlikely to show further improvement on traditional DMARDs at 12 months. These findings underscore the need for better disease control by an aggressive tight control strategy, including intense patient education and biologic therapy.

Clade-related phenotypic switching among fluconazole resistant Candida albicans isolates.

INTRODUCTION: C. albicans undergoes phenotypic switchng, a putative virulence trait assisting the organism to adapt to different environments. Although this switching has been studied among C. albicans isolates, not much is known about the process among various C. albicans clades (a group of genetic variants within a single species). AIM: To determine whether phenotypic switching among fluconazole resistant C. albicans isolates is clade-related. METHODS: Fifteen fluconazole resistant C. albicans isolates from different clades were studied. Phenotypic switching was determined by a method previously described. Switching behaviour and different colony morphologies among different clades were compared. RESULTS: Phenotypic switching was observed in all clades, with clade SA exhibiting the most switching (75%), and clade NG the east (5.6%). Stipple was the most dominant phenotype observed in all clades (p = 0.024), occurring mostly in clade SA (35%). Irregular wrinkle phenotype was dominant in clade SA (62%). CONCLUSION: Phenotypic switching was clade-related. Highest switching in clade SA isolates suggests better survival un der adverse conditions. Stipple and irregular wrinkle phenotypes among clade SA isolates need to be studied further.

Antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus isolates from South Africa.

OBJECTIVE: Trends in the antibiotic susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) are regularly investigated in many countries, but minimal countrywide data are available for South Africa. The aim of this study was to describe the antibiotic susceptibility patterns of MRSA isolates collected in South Africa. DESIGN: Susceptibility testing of 248 MRSA isolates collected from 15 National Health Laboratory Services (NHLS) and 8 private laboratories against 17 antibiotics was performed using the disc diffusion method. Demographic data were collected and correlated with antibiotic resistance patterns. RESULTS: Antibiotic resistance of MRSA to erythromycin, tetracycline, trimethoprim/sulfamethoxazole, gentamicin and ciprofloxacin ranged between 55% and 78%, while all isolates were susceptible to teicoplanin, linezolid, vancomycin and quinopristin/dalfopristin. A significant difference in the resistance pattern of the isolates towards certain antimicrobial agents was identified among adults and children, as well as between isolates collected from the private and NHLS laboratories. CONCLUSION: This is the first extensive report on the antimicrobial susceptibilities of South African MRSA isolates. These data can assist treatment decisions and form a baseline for further surveillance.

Osteoarticular tuberculosis in patients with systemic lupus erythematosus.

BACKGROUND: Systemic lupus erythematosus (SLE) patients are at increased risk of developing tuberculosis (TB), particularly extrapulmonary TB (ExP-TB). AIM: The present study was undertaken to investigate whether SLE patients showed increased susceptibility to develop osteoarticular TB (OA-TB). DESIGN AND METHODS: We retrospectively reviewed and compared the frequency of ExP-TB, in particular OA-TB, in patients with SLE at a tertiary hospital in South Africa, to a non-SLE control TB group seen at the same hospital. RESULTS: TB was diagnosed 111 times in 97 (17%) of the 568 SLE patients. The relative frequency of ExP-TB in the SLE group (25.2%) was significantly lower than in the control group (38.5%) (OR = 1.9, P = 0.006). In contrast, OA-TB was diagnosed in the SLE group in nine (8.1%) patients (seven with peripheral arthritis and two with TB spine) compared to 54 (0.4%) in the overall control group (OR = 20.8, P < 0.001) and 13 (0.2%) in the subgroup of known HIV positive patients in the control group (OR = 44.4, P < 0.001). Within the SLE group, Black ethnicity (P = 0.003), lymphopaenia (P = 0.001), C3/C4 hypocomplementaemia (P = 0.05), corticosteroids [maximum dose (P = 0.002) and duration of treatment (P = 0.02)] and immunosuppressive agents (P = 0.02) were risk factors for TB. Duration of corticosteroid therapy was the only risk factor for OA-TB (P = 0.04). CONCLUSION: While the relative frequency of ExP-TB was lower in the SLE group compared to the control group, our findings suggest that SLE patients are at particular risk of developing OA-TB. Further prospective studies are needed to better understand the mechanisms that predispose SLE patients to OA-TB.